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Scott Weingart. EMCrit Wee: The Lewis Lead and a course in ECGs with Christopher Watford. EMCrit Blog. Published on February 15, 2012. Accessed on September 15th 2019. Available at [https://emcrit.org/emcrit/lewis-lead/ ].

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Unless otherwise noted at the top of the post, the speaker(s) and related parties have no relevant financial disclosures.

I should disclose that I’ve been an associate editor at the EMS 12-Lead blog for about a year now, so you can take that recommendation with a grain of salt 😉

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7 years ago

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Mike Jasumback

I’ll have to try this. Back in the olden days (think Lifepack 3) We simply put RT arm lead on the sternum and the Lt leg lead on the back and set it for lead II. Looks directly through the atrium. I actually had to do this two nights ago to determine whether someone was in AF with slow RVR or 3rd degree heart block.

I’ll have to try the thru-the-chest look. I’ll post some 3-Leads that compare the two views. The nice thing with the thru-the-chest view is the ventricular vector like likely pointing away from it.

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7 years ago

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Mike Jasumback

Ok,
P.s. I second the recommendation for the CCTMC conference for those interested in out of hospital care. I’m speaking on Sepsis (so that’s probably a waste of your time) and the rest of the conference is phenomenal for state of the art transport medicine

Mike J.

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7 years ago

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Minh Le Cong

nice tip Chris! must try that one out. Do y really find it useful in the prehospital setting.?
Love the idea of the opening talk for the air medical conference!

To date I’ve used it twice: on a VT versus SVT versus PMT patient and a ST versus a slower Atrial Flutter patient. In the former it provided no additional data, in the latter it confirmed atrial flutter.

If I use it in the field I will have completed a 12-Lead, tried doubling the gain and compared II, V1, and V6 on a long rhythm strip…if I’m still searching at that point I’ll place the Lewis Leads. I will admit I don’t hold strict to which two limb electrodes get chosen, you just have to remember which lead to view!

i’ve now found a few cases of flutter, a 3rd degree block with p-waves that were indiscernible on 12 lead, and a sinus brady with BBB that looked like vent escape.

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7 years ago

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Bill Hinckley

Scott, thanks for the shout! There’s no better clinical conference dedicated to transport medicine in the US than CCTMC. I’d love to see you there one of these years; until then, I’ll keep preaching the Emcrit gospel. Mike, I look forward to your sepsis talk! Chris, you taught me something completely new today. Thank you.

Christopher is far too humble to plug it heavily, so I’ll do it for him. The EMS 12-Lead Blog (Tom Bouthillet’s along with Christopher and David Baumrind) is probably the best single educational resource online for learning the ECG. It’s 100% free, diligently maintained, and exercises a depth and breadth that is valuable for every level of care. For developing a skill that remains very relevant, and yet is somewhat on the decline in healthcare today, I think it’s an invaluable resource and one of the best examples I know of what web-based education can do. I myself owe a huge amount of my understanding of the ECG to Tom et al., and know many others in a similar position. Their team continues to hammer away in the bitmines for no particular reward, so send some traffic their way and let’s take a moment to applaud them!

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7 years ago

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Mike Sherriff

Chris has outlined an excellent path to ECG mastery, but I would also add to Structured Learning: Garcia and Miller’s “Arrhythmia recognition: the art of interpretation.” Where Garcia’s 12-lead book will really help with basic 12-lead interpretation, Garcia’s arrhythmia book will help one learn an “intermediate” level of rhythm interpretation. It addresses concepts in a straightforward, graphics rich, manner similar to his 12-lead book ; but goes beyond basic generalizations like SVT to teach AVNRT, AVRT, pacemaker rhythms, etc. I have to say Amal Mattu’s 2 books of ECG’s for the Emergency Physician really increased my comfort level. I did 4 ECG’s each morning after cleaning the ambulance (like my morning cross-words), and by the time I was halfway through the second book, I felt pretty strong! Another resource that I’ve just discovered is Dr. Sean Fox’s Academic Emergency Medicine Education Masters at mededmasters.com. Dr. Fox is from Carolina’s Medical Center and has a lot of great education on the site, but an absolute gem for us ECG nerds is located there: Short video ECG lessons by Amal Mattu! http://www.mededmasters.com/ecg-lessons-by-amal-mattu1.html I’ll close by saying: It makes me proud that paramedics like Chris and Tom (and many others) are out there… Read more »

Great segment Scott. And great ECG nuggets Chris and Mike. Now I have two third options after increasing the paper rate and gain. Thanks for all the ECG resources – I’ve been looking for a way to brush up and I’ll be passing them on to all our trainees.

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7 years ago

Clinical Case 049: the Unseen ECG | Broome Docs

[…] The true ECG showed a tachy @ 126 with a RBBB pattern and no convincing P waves. So channeling Chris Watford (Emcrit) I did a Lewis lead config – and the P-waves popped up like they should! Sweet – we were back to boring old sinus […]

One more resource for you: one of our EM residents pointed me to this site, http://www.emedu.org/ecg/
which has some good markups of various conditions. There is a Quiz function on the site which is quite useful.

[…] So if you’re uncertain whether these are retrograde P-waves, and are wondering if you are missing sinus tachycardia, and the patient is stable (as here), you can try Lewis leads to see if sinus P-waves appear. It takes about 30 seconds to align Lewis leads and then switch to lead I to see the result. Aaron continues: Bedside cardiac US demonstrated a hyperdynamic and tachycardic heart with IVC variation with each breath, suggesting volume depletion, as we initially suspected. Fluid resuscitation was started but the rate stayed between 160 and 170. Smith comment: assessing response to volume repletion is a great way to confirm sinus tach. Sinus is an automatic rhythm with varying rate, where re-entrant rhythms such as PSVT are always at a constant rate. If the rate slowly drifts down, this confirms sinus. If the rate does not change, you have not confirmed a non-sinus rhythm, but you have made it far more likely. Aaron continues: The physicians then re-arranged the limb leads of the 12-lead ECG in the Lewis Leads pattern, in order to better identify P-waves, or lack thereof. Smith comment: it is much easier to use the monitor leads for Lewis lead placement than to use the… Read more »